Search

Objective: Many factors influence patient flow through an ED, including streaming, treatment spaces and staff resources. This pilot study explored and compared real time patient flow using a single‐stream system versus varying configurations of possible two‐stream systems using computer simulation. Methods: Simulation modelling was used to assess the delay in treatment of a rapid‐antigen‐tested‐based, two‐stream model for patient flow through ED during the peak phase of the COVID pandemic. Results: Modelling two‐stream configuration for all patients (minimum time to be seen for both COVID‐positive and COVID‐negative patients) showed that in the case study ED, a two‐stream system and linked changes in bed configuration for managing the risks of infection can impact delays in treatment. Conclusions: Data‐driven modelling within specific clinical settings can inform the (in)efficiency of patient flow processes and help clinicians and managers make evidence‐based decisions about patient transition through EDs. This can assist with reconfiguration of ED patient streaming particularly during periods of unique need, such as the recent COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion We aimed to assess the impact a Virtual Toxicology Service had on the ALOS of poisoned patients.This single‐centre before‐after study compares the ALOS of poisoned patients (diagnosis‐related group X62, poisoning/toxic effects of drugs and other substances) following the introduction of a Virtual Toxicology Service in 2020.The ALOS decreased from 0.89 days in the 2‐year pre‐intervention period to 0.62 days in the 3‐year post‐intervention period, with a potential bed saving of 703 days.The introduction of a Virtual Toxicology Service appeared to be associated with a decreased ALOS of poisoned patients. [ABSTRACT FROM AUTHOR]

The provision of waiting time information in emergency departments (ED) has become an increasingly popular practice due to its positive impact on patient experience and ED demand management. However, little scientific attention has been given to the quality and quantity of waiting time information presented to patients. To improve both aspects, we propose a set of state space models with flexible error structures to forecast ED waiting time for low acuity patients. Our approach utilizes a Bayesian framework to generate uncertainties associated with the forecasts. We find that the state‐space models with flexible error structures significantly improve forecast accuracy of ED waiting time compared to the benchmark, which is the rolling average model. Specifically, incorporating time‐varying and correlated error terms reduces the root mean squared errors of the benchmark by 10%. Furthermore, treating zero‐recorded waiting times as unobserved values improves forecast performance. Our proposed model has the ability to provide patient‐centric waiting time information. By offering more accurate and informative waiting time information, our model can help patients make better informed decisions and ultimately enhance their ED experience. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of QScript implementation on pregabalin‐related poisoning presentations to the ED. Methods: This is a retrospective review of pregabalin‐related poisoning presentations to a tertiary Australian ED in the 4 years prior to, and 1 year following the introduction of QScript real‐time prescription monitoring system. Results: Pregabalin‐related poisoning presentations fell by 28% from an average of 98 presentations annually over the 4 years prior to QScript implementation to 71 in 2022. The severity of poisonings was similar over the periods. Conclusions: The introduction of QScript was associated with a reduction in pregabalin‐related poisoning presentations. [ABSTRACT FROM AUTHOR]

Objectives: To compare time metrics associated with a temporary disruption to ED computed tomography (CT) scanner location from adjacent to the ED with direct access from resuscitation rooms, to a location remote to the ED. Methods: A retrospective before and after study was conducted in a public metropolitan ED with over 66 000 presentations annually. Time‐to‐CT metrics, operational time metrics and ED length of stay were extracted and analysed from presentations between October 2020 and January 2021. Results: There were 3031 CT scans during the study period. Overall, the disruption was associated with a significant 27–36 min delay (P < 0.01) in time‐to‐CT start; these delays were also observed in a subset of trauma patients. In a subset of presumed stroke patients, time‐to‐brain perfusion was significantly delayed by up to 10 min (P < 0.01). There was a 14% (P < 0.01) greater demand for operational services and a time imposition of up to 8 min (P < 0.01) to transport patients to or from CT scanning when the CT scanner was located away from the ED. ED length of stay was consistent at all time points. Conclusion: Although rapid, proximate access to CT scanning is often considered desirable in terms of the management of trauma and other time‐critical emergencies, the wider time and resource implications demonstrated in this study suggest a potential broader benefit to co‐located CT scanning in ED. Our experience could be considered in future re‐design of EDs. [ABSTRACT FROM AUTHOR]

The article presents the discussion on telemedicine and digital technologies supporting the provision of emergency care for more than 20 years. Topics include enabling ubiquitous, high quality, secure video conferencing, remote monitoring and digital ordering and review of investigations; and implications for the emergency and primary care workforces, particularly in rural and regional centres.

The purpose of this paper is to demonstrate through practical application how a system dynamics (SD) patient flow model of an emergency department (ED) can show which levers effectively reduce backlogs to improve access to care. Overcrowded EDs are struggling to meet demand and access targets. In 2016 and 2017, in the UK and Australia, respectively, 15% and 28% of arrivals waited longer than the targeted 4‐hr treatment time. Historically, simulation models that have informed access to emergency care have ignored the wider systems impacts. There is a growing awareness of the value of systems analysis tools for informing interventions and policy. In this study, we constructed a pilot system dynamics patient flow model, where the scope was the ambulatory and ambulance patient arrivals, the ED processes for acute and fast‐track pathways, pathology and radiology services, the ED short‐stay unit, and the Medical Assessment Planning Inpatient Unit. Patients queued to access constrained ED resources (doctors and beds) and diagnostic services (pathology and X‐ray). The model was tested on actual data from five separate historical periods spanning 3 years. The resultant daily pattern of peaks and troughs in patient flow and system delays accurately replicated patterns in actual patient flows, resource use, and the location of delays. "What if" scenario analysis (b) simulated how access would have looked in the sample weeks with different intervention strategies, (b) simulated system limits on the basis of current resources, (c) accurately identified levers that historically have been most effective at minimizing ambulance ramping, and (d) identified when additional staffing would fail to improve flow. [ABSTRACT FROM AUTHOR]

The Reserve Bank of Australia is the sole issuer and redeemer of Australian banknotes, but between issuance and destruction there is little information about where banknotes go or what they are used for. We estimate the whereabouts and uses of Australian banknotes, and find that 15–35 per cent are used to facilitate legitimate transactions, 4–7 per cent are used for transactions in the shadow economy, while the remainder are non‐transactional. The vast majority of non‐transactional banknotes are likely to be hoarded, and we estimate that 5–10 per cent of outstanding banknotes are lost or collected. [ABSTRACT FROM AUTHOR]

Traditional and current approaches to modelling the impacts of health care interventions have focused on detail complexity and been ceteris paribus dependent and thereby ignored the wider system impacts. In this study, we have demonstrated that system dynamics (SD) offers theoretical and practical advantages over conventional methodologies and the qualitative assessment tools that have informed the business of emergency care. We translate the key findings of qualitative research, existing literature reviews and studies of the use of simulation and economic evaluation models into a value proposition for using SD tools. We conclude that there is growing evidence of a strong value proposition for the use of SD tools to investigate interventions targeting improved emergency care access. SD models can incorporate dynamic and organizational complexity and fill a gap beyond the microscope of the conventional methodologies informing health care. This potential to strengthen health care systems warrants further investigation. [ABSTRACT FROM AUTHOR]

After successfully avoiding the situations experienced by some countries, Australasian EDs now face a future in which the ongoing threat of COVID‐19 is added to the traditional challenges in providing quality emergency care. The contribution of emergency medicine to the national containment strategy adds a new dimension to the demands placed on emergency medicine in Australia and similarly, to the elimination strategy employed in New Zealand. These demands will best be met by a considered, planned and resourced approach that will challenge traditional measures of 'ED efficiency'. [ABSTRACT FROM AUTHOR]

Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has led to the development of alternative means of accessing unplanned care in order to avoid unnecessary ED presentations and hospital admissions. We explore the definition of emergency medicine, which patients are better served by accessing unplanned hospital care via alternative pathways, and the concept of emergency care completion. [ABSTRACT FROM AUTHOR]

The article focuses on the challenges at the Princess Alexandra Hospital (PAH) in Australia for transforming into an integrated digital tertiary hospital, with topics including the use of electronic medical records (EMR) in the hospital, medical technology management, and the medical care quality.

Objective: The aim of the present study was to investigate the feasibility of using a store-and-forward Skin Emergency Telemedicine Service (SETS) to provide rapid specialist diagnostic and management advice for dermatological cases in an ED. Methods: This pilot study was conducted at the Princess Alexandra Hospital between August 2008 and August 2009. Study subjects were consenting patients over 18 years of age who presented with a dermatological condition to the ED. The ED doctor sent the patient's history, examination findings and the digital images of the skin conditions to a secure email address, which automatically forwarded this to the teledermatologist. The teledermatologist reviewed the cases and sent advice on diagnosis and management to the referring ED doctor via email and/or telephone. Face-to-face follow-up consultations with the patients were conducted within 2 weeks. The diagnostic and management concordance between ED doctors, teledermatologists and reviewing dermatologists were analysed. Results: A total of 60 patients participated in the present study. SETS provided a rapid response with 56 (93%) of ED consultations receiving a dermatology opinion within 2 h. Face-to-face follow up occurred in 50 patients (83%). Statistical analysis showed significant levels of agreement between tele-diagnosis and ED diagnosis of 71.2% (Kappa 0.42) and tele-diagnosis and final clinical diagnosis of 98% (Kappa: 0.93). The clinical management concordance was 96% in complete agreement and 4% in relative agreement between the teledermatologists and reviewing dermatologists, based on chart review. Conclusion: The present study has shown that SETS can provide rapid and accurate diagnostic and treatment advice from a specialist for dermatological presentations to the ED. [ABSTRACT FROM AUTHOR]

Abstract Objective: The aim of the study was to determine the range of cerebrospinal fluid findings associated with emergency department disposition and treatment of patients with headache suspicious of subarachnoid haemorrhage but a negative or equivocal computed tomoraphy head scan, in particular the role of xanthochromic index. Methods: A retrospective review of medical records of 196 adult patients who underwent cerebrospinal fluid examination for red cell count and xanthochromia for suspected subarachnoid haemorrhage but had a normal or equivocal computed tomography scan. Results: Included in the study were 196 patients. Only one patient out of 189 with a negative computed tomography scan was found to have a subarachnoid haemorrhage caused by a ruptured aneurysm (0.5%; 95% confidence intervals 0–2.9%). Three other patients were diagnosed with benign subarachnoid haemorrhage. Ninety-one patients were stratified into the lowest possible risk group for subarachnoid haemorrhage and discharged home from the emergency department. All patients with equivocal computed tomography head scans and a positive xanthochromic index were admitted for cerebral angiography. In many cases, cerebrospinal fluid findings did not appear to influence clinical decision-making. Conclusions: In the study institution, cerebrospinal fluid results appeared to have a variable influence on clinical decision-making for patients with suspected subarachnoid haemorrhage and a non-diagnostic computed tomography head scan. Of particular concern is the lack of validation of the tests used in this investigative approach, the frequency of patients having a lumbar puncture where the results did not influence their management, the inconsistency in the laboratory’s technique for performing tests on cerebrospinal fluid and the very low yield of detecting patients with subarachnoid haemorrhage and a potentially treatable causative lesion. [ABSTRACT FROM AUTHOR]

Patients who require emergency admission to hospital require complex care that can be fragmented, occurring in the ED, across the ED-inpatient interface (EDii) and subsequently, in their destination inpatient ward. Our hospital had poor process efficiency with slow transit times for patients requiring emergency care. ED clinicians alone were able to improve the processes and length of stay for the patients discharged directly from the ED. However, improving the efficiency of care for patients requiring emergency admission to true inpatient wards required collaboration with reluctant inpatient clinicians. The inpatient teams were uninterested in improving time-based measures of care in isolation, but they were motivated by improving patient outcomes. We developed a dashboard showing process measures such as 4 h rule compliance rate coupled with clinically important outcome measures such as inpatient mortality. The EDii dashboard helped unite both ED and inpatient teams in clinical redesign to improve both efficiencies of care and patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: We explored the relationship between the National Emergency Access Target (NEAT) compliance rate, defined as the proportion of patients admitted or discharged from emergency departments (EDs) within 4 hours of presentation, and the risk-adjusted in-hospital mortality of patients admitted to hospital acutely from EDs.Design, Setting and Participants: Retrospective observational study of all de-identified episodes of care involving patients who presented acutely to the EDs of 59 Australian hospitals between 1 July 2010 and 30 June 2014.Main Outcome Measure: The relationship between the risk-adjusted mortality of inpatients admitted acutely from EDs (the emergency hospital standardised mortality ratio [eHSMR]: the ratio of the numbers of observed to expected deaths) and NEAT compliance rates for all presenting patients (total NEAT) and admitted patients (admitted NEAT).Results: ED and inpatient data were aggregated for 12.5 million ED episodes of care and 11.6 million inpatient episodes of care. A highly significant (P < 0.001) linear, inverse relationship between eHSMR and each of total and admitted NEAT compliance rates was found; eHSMR declined to a nadir of 73 as total and admitted NEAT compliance rates rose to about 83% and 65% respectively. Sensitivity analyses found no confounding by the inclusion of palliative care and/or short-stay patients.Conclusion: As NEAT compliance rates increased, in-hospital mortality of emergency admissions declined, although this direct inverse relationship is lost once total and admitted NEAT compliance rates exceed certain levels. This inverse association between NEAT compliance rates and in-hospital mortality should be considered when formulating targets for access to emergency care. [ABSTRACT FROM AUTHOR]

Discusses the issue of the misleading interpretation of the term xanthochromic in immunohistochemistry. Guidelines regarding the use of the term proposed by the British NEQAS; Functions of the guidelines.